Resistance to Change
People resist change for a variety of reasons that vary from person to person and situation to situa- tion. You might find that one patient-care techni- cian is delighted with an increase in responsibility, whereas another is upset about it. Some people are eager to make changes; others prefer the status quo (Hansten & Washburn, 1999). Managers may find that one change in routine provokes a storm of protest and that another is hardly noticed. Why does this happen? We will first consider why people may be ready for change and why they may resist change.
Receptivity to Change Preference for Certainty
An interesting research study on nurses’ preferred information processing styles suggests that nurse managers were more receptive to change than were their staff members (Kalisch, 2007). Nurse manag-
ers were found to be innovative and decisive, whereas staff nurses preferred “proven” approaches and were resistant to change. Nursing assistants, unit secretaries, and licensed practical nurses were also unreceptive to change, adding layers of people who formed a “solid wall of resistance” to change.
Kalisch suggests that helping teams recognize their preference for certainty (as opposed to change) will increase their receptivity to necessary changes in the workplace.
Speaking to People’s Feelings
Although both thinking and feeling responses to change are important, Kotter (1999) says that the heart of responses to change lies in the emotions surrounding it. He suggests that a compelling story will increase receptivity to a change more than a carefully crafted analysis of the need for change. It is more likely to create that sense of urgency needed to stimulate change (Braungardt & Fought, 2008;
Shirey, 2011). How is this done? The following are some examples of appeals to feelings.
■ Instead of presenting statistics about the number of people who are re-admitted due to poor discharge preparation, providing a story may be more persuasive. For example, you can tell the staff about a patient who collapsed at home the evening after discharge because he had not been able to control his diabetes post-surgery. Trying to break his fall, he fractured both wrists and needed surgical repair. With broken wrists, he is now unable to return home or take care of himself.
■ Even better, videotape an interview with this man, letting him tell his story and describe the repercussions of poor preparation for discharge.
■ Drama may also be achieved through visual display. A culture plate of pathogens grown from swabs of ventilator equipment and patient room furniture is more attention- getting than an infection control report. A display of disposables with price tags attached for just one patient is more memorable than an accounting sheet listing the costs.
The purpose of these activities is to present a com- pelling image that will affect people emotionally, increasing their receptivity to change and moving them into a state of readiness to change (Kotter, 1999).
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Sources of Resistance
Resistance to change comes from three major sources: technical concerns, relation to personal needs, and threats to a person’s position and power (Araujo Group).
Technical Concerns
The change itself may have design flaws. Resistance may be based on concerns about whether the pro- posed change is a good idea.
The Professional Practice Committee of a small hos- pital suggested replacing a commercial mouthwash with a mixture of hydrogen peroxide and water in order to save money. A staff nurse objected to this proposed change, saying that she had read a research study several years ago that found peroxide solutions to be an irritant to the oral mucosa (Tombes &
Gallucci, 1993). A later review of the research noted that this depended on the concentration used (Hos- sainian, Slot, Afennich, & Van der Weijden, 2011).
Fortunately, the chairperson of the committee recog- nized that this objection was based on technical concerns and requested a thorough study of the evi- dence before instituting the change. “It’s important to investigate the evidence supporting a proposed change thoroughly before recommending it,” she said.
A change may provoke resistance for practical reasons. For example, if the bar codes on patients’
armbands are difficult to scan, nurses may develop a way to work around this safety feature by taping a duplicate armband to the bed or to a clipboard, defeating the electronically monitored medication system (Englebright & Franklin, 2005).
Personal Needs
Change often creates anxiety, much of it related to what people fear they might lose (Berman-Rubera, 2008; Johnston, 2008). Human beings have a hier- archy of needs, from the basic physiological needs to the higher-order needs for belonging, self- esteem, and self-actualization (Fig. 9.2). Maslow (1970) observed that the more basic needs (those lower on the hierarchy) must be at least partially met before a person is motivated to seek fulfillment of the higher-order needs.
Change may make it more difficult for a person to meet any or all of his or her needs. It may threaten safety and security needs. For example, if
a massive downsizing occurs and a person’s job is eliminated, needs ranging from having enough money to pay for food and shelter to opportunities to fulfill one’s career potential are likely to be threatened.
In other cases, the threat is subtler and may be harder to anticipate. For example, an institution- wide reevaluation of the effectiveness of the ad- vanced practice role would be a great concern to a staff nurse who is working toward accomplishing a lifelong dream of becoming an advanced practice nurse in oncology. Staff reorganization that moves some staff members to different units could chal- lenge the belonging needs of those who have close friends on the unit but few friends outside of work.
Position and Power
Once gained within an organization, status, power, and influence are hard to relinquish. This applies to people anywhere in the organization, not just those at the top. For example:
A clerk in the surgical suite had been preparing the operating room schedule for many years. Although his supervisor was expected to review the schedule
Highest Level
Lowest Level Self-actualization
Growth, development, fulfill potential
Esteem Self-esteem, respect,
recognition
Love and belonging Acceptance, approval,
inclusion, friendship
Safety and security Physical safety, trust, stability, assistance
Physiological needs Air, water, food, sleep, shelter, sex, stimulation
Figure 9.2 Maslow’s hierarchy of needs. Based on Maslow, A.H. (1970). Motivation and Personality. New York:
Harper & Row.
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before it was posted, she rarely did so because the clerk was skillful in balancing the needs of various parties, including some very demanding surgeons.
When the supervisor was transferred to another facility, her replacement decided that she had to review the schedules before they were posted because they were ultimately her responsibility. The clerk became defensive. He tried to avoid the new super- visor and posted the schedules without her approval.
This surprised her. She knew the clerk did this well and did not think that her review of them would be threatening.
Why did this happen? The supervisor had not real- ized the importance of this task to the clerk. The opportunity to tell others when and where they could perform surgery gave the clerk a feeling of power and importance. The supervisor’s insistence on reviewing his work reduced the importance of his position. What seemed to the new supervisor to be a very small change in routine had provoked surprisingly strong resistance because it threatened the clerk’s sense of importance and power.
Recognizing Resistance
Resistance may be active or passive (Heller, 1998).
It is easy to recognize resistance to a change when it is expressed directly. When a person says to you,
“That’s not a very good idea,” “I’ll quit if you sched- ule me for the night shift,” or “There’s no way I’m going to do that,” there is no doubt you are encoun- tering resistance. Active resistance can take the form of outright refusal to comply, writing memos that destroy the idea, quoting existing rules that make the change difficult to implement, or encour- aging others to resist.
When resistance is less direct, however, it can be difficult to recognize unless you know what to look for. Passive approaches usually involve avoidance:
canceling appointments to discuss implementation of the change, being “too busy” to make the change, refusing to commit to changing, agreeing to it but doing nothing to change, and simply ignoring the entire process as much as possible (Table 9-1).
Once resistance has been recognized, action can be taken to lower or even eliminate it.
Lowering Resistance
A great deal can be done to lower people’s resis- tance to change. Strategies fall into four categories:
sharing information, disconfirming currently held
beliefs, providing psychological safety, and dictating (forcing) change (Tappen, 2001).
Sharing Information
Much resistance is simply the result of misunder- standing a proposed change. Sharing information about the proposed change can be done on a one- to-one basis, in group meetings, or through written materials distributed to everyone involved via print or electronic means.
Disconf irming Currently Held Beliefs
Disconfirming current beliefs is a primary force for change (Schein, 2004). Providing evidence that what people are currently doing is inadequate, incorrect, inefficient, or unsafe can increase people’s willingness to change. For example, Lindberg and Clancy (2010) note a widespread belief in the inevi- tability of health-care associated infections, that they are unfortunate but unavoidable. To imple- ment a successful campaign to reduce infection rates, this myth would have to be dispelled. The dramatic presentations described in the section on receptivity help to disconfirm current beliefs and practices. The following is a less dramatic example but still persuasive:
Jolene was a little nervous when her turn came to present information to the Clinical Practice Com- mittee on a new enteral feeding procedure. Commit- tee members were very demanding: they wanted clear, evidence-based information presented in a concise manner. Opinions and generalities were not acceptable. Jolene had prepared thoroughly and had practiced her presentation at home until she could speak without referring to her notes. The presenta- tion went well. Committee members commented on how thorough she was and on the quality of the information presented. To her disappointment, however, no action was taken on her proposal.
table 9-1
Resistance to Change
Active Passive
Attacking the idea Avoiding discussion Refusing to change Ignoring the change Arguing against the change Refusing to commit to the
change Organizing resistance of other
people
Agreeing but not acting
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Returning to her unit, she shared her disappoint- ment with the nurse manager. Together, they used the unfreezing-change-refreezing process as a guide to review the presentation. The nurse manager agreed that Jolene had thoroughly reviewed the information on enteral feeding. The problem, she explained, was that Jolene had not attended to the need to unfreeze the situation. Jolene realized that she had not put any emphasis on the high risk of contamination and resulting gastrointestinal dis- turbances of the procedure currently in use. She had left members of the committee still comfortable with current practice because she had not emphasized the risk involved in failing to change it.
At the next meeting, Jolene presented addi- tional information on the risks associated with the current enteral feeding procedures. This discon- firming evidence was persuasive. The committee accepted her proposal to adopt the new, lower-risk procedure.
Without the addition of the disconfirming evi- dence, it is likely that Jolene’s proposed change would never have been implemented. The inertia (tendency to remain in the same state rather than to move toward change) exhibited by the Clinical Practice Committee is not unusual (Pearcey &
Draper, 1996).
Providing Psychological Safety
As indicated earlier, a proposed change can threaten people’s basic needs. Resistance can be lowered by reducing that threat, leaving people feeling more comfortable with the change. Each situation poses different kinds of threats and, therefore, requires different actions to reduce the levels of threat; the following is a list of useful strategies to increase psychological safety:
■ Express approval of people’s interest in providing the best care possible.
■ Recognize the competence and skill of the people involved.
■ Provide assurance (if possible) that no one will lose his or her position because of the change.
■ Suggest ways in which the change can provide new opportunities and challenges (new ways to increase self-esteem and self-actualization).
■ Involve as many people as possible in the design or plan to implement change.
■ Provide opportunities for people to express their feelings and ask questions about the proposed change.
■ Allow time for practice and learning of any new procedures before a change is
implemented.
Dictating Change
This is an entirely different approach to change.
People in authority in an organization can simply require people to make a change in what they are doing or can reassign people to new positions (Porter-O’Grady, 1996). This may not work well if there are ways for people to resist, however, such as in the following situations:
■ When passive resistance can undermine the change
■ When high motivational levels are necessary to make the change successful
■ When people can refuse to obey the order without negative consequences
The following is an example of an unsuccessful attempt to dictate change:
A new, insecure nurse manager believed that her staff members were taking advantage of her inex- perience by taking more than the two 15-minute coffee breaks allowed during an 8-hour shift. She decided that staff members would have to sign in and out for their coffee breaks and their 30-minute meal break. Staff members were outraged by this new policy. Most had been taking fewer than 15 minutes for coffee breaks or 30 minutes for lunch because of the heavy care demands of the unit. They refused to sign the coffee break sheet. When asked why they had not signed it, they replied, “I forgot,”
“I couldn’t find it,” or “I was called away before I had a chance.” This organized passive resistance was sufficient to overcome the nurse manager’s author- ity. The nurse manager decided that the coffee break sheet had been a mistake, removed it from the bul- letin board, and never mentioned it again.
For people in authority, dictating a change often seems to be the easiest way to institute change: just tell people what to do, and do not listen to any arguments. There is risk in this approach, however.
Even when staff members do not resist authority- based change, overuse of dictates can lead to a
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passive, dependent, unmotivated, and unempow- ered staff. Providing high-quality patient care requires staff members who are active, motivated, and highly committed to their work.