The Nurse as Change Agent and Advocate

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The Nurse as Change Agent and Advocate

  • Chapter 8

Origins of Change

  • Began in the 1990s
  • Continuing increase in health care costs
  • Employees expected to become multiskilled
  • Presents challenges for both providers and consumers

Types of Change

  • Developmental change-
    • changes or improvements in currently used processes and operations
  • Transitional change-
    • Moves into a different pattern of operation and structure
  • Transformational change-
    • creates a whole new set of attitudes and appproaches


  • Driving forces for change
    • See page 300 for examples of driving and restraining forces
    • External forces
      • Insurance companies
      • Government
      • New technology
      • See page 300 for examples of
    • Internal forces
  • Planned –deliberate and conscious
  • Unplanned- reactive change

Theories of Change

  • Bridges’ transformational change
    • Focuses on transitions of attitudes and beliefs
    • Old must be given up
  • Lewin’s force field theory of change
  • Coghlan and McAuliffe
    • 5 tasks of change- determining the need, defining the desired state, assessing, implementing and managing it, and consolidating it


  • Change in our health care delivery system is an ongoing process. The view that stability in any organization or system is achieved through a balance or equilibrium of forces acting on the situation is a component of which theory of change?
  • A. Coghlan and McAuliffe
  • B. Bridges
  • C. Lewin
  • D. Bennis and Chin


  • C. Lewin
  • Rationale: another theory of change is the force-field analysis described by Lewin. Force-field analysis begins with the view that stability in any organization or system is achieved through a balance or equilibrium of forces acting on the situation (Lewin, 1951).

Strategies for Creating Change

  • Environmental and adaptive strategy
  • Power-coercive strategy
    • Leader orders change
  • Empirical-rational strategy-
  • Normative-reeducative strategy (most common)
    • Change will take place only after attitudes, values, skills etc. change

Leading and Managing Change

  • Role of the change agent
    • The person who seeks to lead or create change
    • Demonstrate your commitment to change
    • Believe in the necessity for planned change
  • Managers of change
    • Quality patient care continues
    • Staff feel supported in doing their jobs
    • Adverse effects of the change are mitigated

Facilitating the Change Process

  • Assessing the situation
    • Identifying driving and restraining forces
    • Understanding losses associated with change
    • Recognizing resistance to change
      • Lack of trust can be key
      • Fear and loss of control
      • Change fatigue- feel overwhelmed by the expectations and lose enthusiasm
    • Self-assessment
  • Planning for change
    • Developing trust
        • Listening is very important
    • Planning a response to concerns
    • Fostering involvement
    • Timing the change
  • Facilitating the Change Process (cont’d)

Implementing the change

  • Implementing the change
    • Using a pilot project
    • Providing resources and supports for change
    • Managing the time frame
    • Interpersonal processes for change
    • Sustaining the change- “refreezing”
    • Monitoring and evaluating the change process- story board
  • Facilitating the Change Process


  • Is the following statement true or false?
  • One reason that change fails is recognizing the losses inherent in change.


  • False.
  • Rationale: as mentioned earlier, Bridges (2003) suggests that there are many losses in any change and failure to acknowledge that loss is present is one reason for the failure of change.

Effectively Participating in Change

  • Understanding the change
  • What is your place in the change?
    • Viewed as positive or negative
    • Participation is essential

Change Through Advocacy

  • Definitions
    • Pleading or arguing in favor of something
    • Mediation- helping 2 parties work out an agreement
      • Broker or responsible model- negotiation, compromise and persuasion
      • Adversarial model or legalistic- focus on rights of the client without concern for others
    • Empowerment of individual- advocate for self
  • Background
    • Ombudsman program (1978 Nursing Homes)
    • American Nurses Association- ethical standard

Change Through Advocacy (cont’d)

  • Prerequisite to effective advocacy
    • Identify and define your own beliefs and values
      • Avoid paternalism- making decisions for the person
    • Clinical competence
    • Believe that you have the right to speak up

Change Through Advocacy (cont’d)

  • Assessing the need for advocacy
    • Those who lack knowledge
    • Those with little power
    • Those who need to make decisions
    • Those who receive inadequate care
    • Those who are unable to communicate for themselves


  • What is a prerequisite to being an effective advocate?
  • A. Believe you know what is best for your client.
  • B. Define your own beliefs and values.
  • C. Identify what family members believe and value.
  • D. Be supportive of other health care personnel.


  • B. Define your own beliefs and values.
  • Rationale: before being a client advocate, you must identify and define your own beliefs and values.

Advocacy Goals

Advocacy Outcomes

Advocacy Actions

  • Preventing the need for advocacy
  • Providing information and education
  • Assisting and supporting client’s decision making

Communicating with Health Care Professionals

  • Demonstrate knowledge and tact
  • Include information about the client’s concerns, questions, and expectations
  • Call the appropriate physician
  • Encourage direct communication between the client and the appropriate health care providers

Working for Changes in the Health Care System

  • Advocate through understanding
    • Organizational structure
    • Volunteer for ethics committee
  • Make sure resources are available

Being Involved in Public Policy Formulation

  • Expertise to be an advocate for the health care needs
  • Support legislation that benefits health care consumers or makes needed services available
  • ANA encourages nurses to step forward as the experts they are to speak to the media


  • One of the ways to be actively involved in the formulation of public policy is:
  • A. Networking with other professionals at a social level
  • B. Volunteering for planning committees in professional organizations
  • C. Knowing who your congressional representatives are
  • D. Being actively involved in nursing organizations that work for programs and services for clients


  • D. Being actively involved in nursing organizations that work for programs and services for clients
  • Rationale: the best ways to be actively involved in formulation of public policy is through nursing organizations that work for programs and services for clients, and network through professional organizations, alumni groups, friends, and coworkers.

Advocating for Other Staff Members

  • Managers must address:
    • Staff needs
    • Staff requests
    • Staff problems
    • Staff rights
  • Requires careful judgment relative to the staff member’s situation and the needs of the
  • agency

Constraints and Supports

  • Constraints
    • Conflict with other staff
    • Lack of supports
    • “Bucking the system”
  • Supports
    • Legal mandate for client rights
    • Personal reward for quality care

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